2023 Rebel Regiment Forms and Fees | James F Byrnes High School Band

Student information Form

Student Information Sheet - 2023-2024

Information collected here is entered into the CutTime database for use related to activities and communication within the James F. Byrnes High School band and guard program.

Student Information
Which band are you in?*
Please choose your experience level*
Student Name*
First Middle Last
Student Address*
Street Address Address Line 2 City State ZIP Code
Student Home Phone (**Land Line Only**)
Student Mobile
Student Email
Enter Email Confirm Email
Instrument (Choose only one)*
Student T-Shirt Size*
Grade (School year 2023-2024)*
Student Gender*
- Female
- Male
Student Date of Birth
MM slash DD slash YYYY
Parent / Guardian Information
Adult 1 Relationship to Student
Adult 1 Name*
First Last
Adult 1 Address
- Same as student
Adult 1 Address (if different than student)
Street Address Address Line 2 City State ZIP Code
Adult 1 Place of Employment | Occupation/Skills
Adult 1 Home Phone
- Same as student
Adult 1 Home Phone (**Land Line** - if different than student)
Adult 1 Work Phone
Adult 1 Mobile*
Adult 1 Email*
Enter Email Confirm Email
Adult 2 Relationship to Student
Adult 2 Name
First Last
Adult 2 Address
- Same as Student
Adult 2 Address (if different than student)
Street Address Address Line 2 City State ZIP Code
Adult 2 Place of Employment | Occupation/Skills
Adult 2 Home Phone
- Same as student
Adult 2 Home Phone (**Land Line** - if different than student)
Adult 2 Work Phone
Adult 2 Mobile
Adult 2 Email
Enter Email Confirm Email
Emergency Contacts
Emergency contacts will be be contacted if a parent/guardian cannot be reached in an emergency. Please provide two emergency contacts in order of preferred contact)
Emergency Contact 1 Relationship to Student*
Emergency Contact 1 Name*
First Last
Emergency Contact 1 Phone*
Emergency Contact 2 Relationship to Student
Emergency Contact 2 Name
First Last
Emergency Contact 2 Phone
Confirmation
Please enter the email of the person completing this form. A confirmation email will be sent to the email address for that person.
Confirmation Email*
Enter Email Confirm Email
Student Health Information
All health information is kept confidential.
Family physician*
Family physician Phone*
Student Health History
Food allergies (please type “none” if none)
Drug allergies (please type “none” if none)
Environmental/Seasonal allergies (please type “none” if none)
Student prescription medication list
STUDENT PRESCRIPTION MEDICATION LIST: (List all medications student is currently taking at home and/or school)
Medicine 1:
Time, Dose and purpose for medication
Medicine 2:
Time, Dose and purpose for medication
Check any box that applies below:
Record of illness, health problems the student currently has or has a history of:
- ADD/ADHD
- Arthritis
- Autism
- Asthma
- Diabetes Type 1, IDDM
- Diabetes Type 2, NIDDM
- Hypoglcemia
- Stomach problems/Gastric Reflux
- Frequent Headaches
- Migraines
- Heart Disease
- Seizures
- Dizziness/Vertigo
- Skin Disorder
- Bladder/Kidney
- Bowel/Colon
- Vision/Glasses/Contacts
- Hearing Aid/Hearing Loss
- Mental Health/Emotional Condition
- Mobility Devices
- Other
Name of Health Insurance Company*
Group or Identification number:*
Parent/Guardian Permission
Parent/Guardian Permission*
This is to certify that my student (type name below) has my permission to participate in all approved band trips, rehearsals and events during the 2022-2023 school year. I also understand that my son/daughter will be participating and that he/she is expected to abide by all school district rules and regulations during the course of the activity or trip. I understand that he/she will be chaperoned by school personnel and/or other approved volunteers. Additionally, if I cannot be reached, I understand and agree that my son/daughter may receive medical treatment in case of injury or illness during a band trip/event. I further agree to indemnify and hold harmless Spartanburg School District Five, staff or chaperones for any accidents, injuries or loss that may occur. The booster club and staff are not responsible for any theft, damage or loss to any instruments or other belongings during any band event. ***Please type student name below***
Signatures
Consent to to business electronically*
The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility. (type your full name as your electronic signature below)
Student Signature*
I promise to follow all school rules and policies during any band related activities. I verify that the information completed is accurate and valid. I have read, understand and agree to the information in the band handbook and permission items listed above.
Parent Signature*
I promise to follow all school rules and policies during any band related activities. I verify that the information completed is accurate and valid. I have read, understand and agree to the information in the band handbook and permission items listed above. (type your name as your electronic signature below)
Untitled

Pay Fees

2022 Rebel Regiment Fees - 8th Football Band

Student Name*
Place separate orders for each student.
First Last
Purchaser Name*
Enter the name of the purchaser
First Last
Email
Enter the purchaser's email address
Enter Email Confirm Email
Phone*
Enter the purchaser's phone number
Trip Fees (Hidden)
This is the "Product" with which the dues payment "options" below are associated. This field is hidden.
Fees
- Payment #1 - $75 Due by May 12th, 2022
- Payment #2 - $75 Due by July 1, 2022
Band Shoes
If band shoes are needed, check the option below to purchase.
- Band Shoes (only if new shoes are needed/new band student; $45
Product Name
This is the "Product" with which the "options" below are associated--band shoes, grays, flag bag, gloves, and sabre rental. This field is hidden.
Processing
3.5% Processing Fee for Band Shoes ONLY
Price: $0.00
Total
$0.00

Student Information Sheet - 2023-2024

Student Information

Parent / Guardian Information

Emergency Contacts

Confirmation

Student Health Information

Student Health History

Student prescription medication list

Parent/Guardian Permission

Signatures

2022 Rebel Regiment Fees - 8th Football Band

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